Serve as the bridge between primary/emergency care and recovery in patients’ homes. Collaborate with nurses in the Post-Discharge Center to reduce repeat ED visits and re-hospitalization of patients. Below are details on the program:

• Reviewing patients record following an emergency room or hospital encounter
• Reviewing initial and or subsequent home health nursing assessment and plan of care
• Writing orders
• Reviewing and signing CMS Form 485 for Home Health (Nursing Assessment and Plan of Care)
• Write and sign applicable clinical orders for approval
• Communicate with nurse on Order Changes to Plan of Care
• Work closely with nurses in Post-Discharge Center to support overall goal of managing patient 30 to 60 days post-acute to reduce repeat ED visits and hospital re-admissions
• Supports both single, post-acute episodes of care, as well as a Bridge to Primary care with support of patient home health needs for up to 60 days

Requirements

• Licensed/living in applicable state
• BC in IM, FM or EM
• Clear practice history
• Strong communication and technical skills